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We studied 21 consecutive patients from the Lausanne Stroke Registry, who had first-ever ischemic stroke and lone atrial fibrillation, with a standard protocol of investigations including brain CT, and non-invasive cardiac and arterial tests. Rarity of associated risk factors and extracranial; arterial disease, presence of distal intracerebral occlusions on early angiography, and topography of cerebral infarct suggested that cardioembolism was the cause of stroke, though echocardiographic evidence for an atrial thrombus was uncommon. There was no recurrence during a post-stroke 14-day phase, during which anticoagulant and antiaggregant therapies were systematically avoided. Though low, the main risk of stroke recurrence was 0.99 per 100 patient-years during a mean follow-up period of 4.8 years, including a mean duration of anticoagulant therapy of 2.3 years in 18 patients. On the other hand, no death, severe cardiac events, or disabling anticoagulation-related hemorrhages occurred.

Autologous fat injection for soft tissue augmentation in the face is claimed to be a safe procedure. However, there are several case reports in the literature where patients have suffered from acute visual loss and cerebral infarction following fat injections into the face. Acute visual loss after injection of various substances into the face is a well-known complication of such interventions. We report two further patients who suffered from ocular and cerebral embolism after fat injections into the face. For the intravasation of fat particles there are three preconditions: well-vascularized tissue, fragmentation of parenchyma, and, especially, a local increase in pressure in the affected tissue. Fat injections into the face lead to an acute local increase in pressure in highly vascularized tissue. We assume that fragments of fatty tissue reach ocular and cerebral arteries by reversed flow through branches of the carotid arteries after they are introduced into facial vessels. The manifestation of fat embolism appears either immediately after the fat injection or after a latency period. Fat embolism can remain subclinical and may not be recognized, or the clinical features may be misinterpreted. To minimize the risk of such a major complication, fat injections should be performed slowly, with the lowest possible force. One should avoid fat injections into pretraumatized soft tissue, for example, after rhytidectomy, because the risk of intravasation of fat particles may be higher. Metabolic disturbances such as hyperlipidemia may also contribute to the clinical manifestation of fat embolism. Routine funduscopic examinations after fat injections into the face could help to provide data for future estimation of the patient's general risk.

We report four patients with various degrees of chronic, tonic, mildly painful, or non-painful, kyphoscolioses in orthostatism, which developed weeks, or months, after one or several laminectomies for lumbar disk hernia, in the absence of recurring radicular pain or acute lumbar pain. No family history or personal antecedent, of focal or generalized dystonia was found and the dystonia was not seen in any of the four patients pre-operatively, or during the immediate post-operative period. Only ill-defined lumbar 'discomfort', unlike their pre-operative lumbago, was reported by the patients, before and during the occurrence of the pathologic trunk posture on standing. Asymmetric lumbar muscle tonic contraction and hypertrophy was found on physical examination. In all patients, the kyphoscoliosis was maximal when standing, partially disappeared when seated, and completely when lying down. One patient responded well to clonazepam, but the other three showed no improvement with either clonazepam or local injections of botulinum toxin; L-dopa was ineffective in all cases, and trihexiphenidyle in three.

We have examined the clinical features of patients with femoral neuropathy and the factors that influence the prognosis. Of 80 consecutive patients referred for neurophysiological evaluations of proximal lower limb weakness, 32 fulfilled strict inclusion criteria and had adequate information, including estimates of axon loss (AxL) by stimulation of the bilateral femoral nerve. In 31, the Kaplan-Meier method was used to describe the time course of the outcome, while logistic regression was employed to determine the contributing factors. Excellent, satisfactory, and poor outcomes were seen in 10 (31%), 11 (34%), and 10 (31%) patients, respectively. Logistic regression analysis of seven factors demonstrated that the estimate of AxL was the only significant variable. The best prognostic factor was an estimate of AxL ≤ 50%, with all patients fulfilling this criterion showing improvement within 1 year; fewer than half the patients with AxL >50% should be expected to improve. This study clearly shows that, irrespective of the cause of femoral neuropathy, functional improvement is seen in 2 out of 3 patients within 2 years and that the estimate of AxL is the only factor influencing prognosis. © 1997 John Wiley & Sons, Inc. Muscle Nerve, 20, 205–211, 1997.

Background: The risk of stroke and the long-term prognosis of recurrent strokes in young patients with patent foramen ovale (PFO) are not well known. For this reason, the treatment of these patients remains empirical. An alternative treatment to prolonged antithrombotic therapy may be surgical closure of the PFO. Methods: Thirty patients (20 men and 10 women) with stroke and PFO were prospectively selected among 138 patients with stroke and PFO for a study of surgical closure of PFO at our center. Eligible patients were 50 microbubbles counted in the left atrium on contrast transesophageal echocardiography (TEE), and (4) Valsalva maneuver or cough preceding the stroke. Patients selected in this manner for surgery were considered to be a subgroup with a higher risk of stroke recurrence. Results: All patients had a direct suture of PFO while under cardiopulmonary bypass without recorded early or delayed significant complication. All patients underwent a new brain MRI and TEE simultaneous with transcranial Doppler ultrasonography after contrast injection at 8 +/- 3 months after surgery. After a mean follow-up of 2 years without antithrombotic treatment, no recurrent cerebrovascular event (stroke or transient ischemic attack [TIA]) and no new lesion on MRI had developed. Postoperative contrast TEE and transcranial Doppler ultrasonography showed that two patients had residual interatrial right-to-left shunting, although much smaller than before surgery, associated with single versus double continuous suture. Conclusions: Our study of 30 selected stroke patients with surgical suture of PFO showed a stroke recurrence rate of 0% and no significant complication. Residual right-to-left shunting may be avoided by double continuous suture of the PFO. In the absence of controlled studies to guide individual therapeutic decisions, our findings show that PFO closure can be done safely and may be considered to avoid recurrence in selected patients with long life expectancy and presumed paradoxic embolism.NEUROLOGY 1996;47: 1162-1166

Using a published protocol, we evaluated a non-selected population of stroke patients to identify unnecessary days of hospitalisation in the Department of Neurology at the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. This study was undertaken to determine whether physicians can modify the non-medically justified hospital days. We prospectively studied 118 patients with stroke admitted to our Department over a period of 5 months. Each day spent on the ward was placed in one of two categories: those due to medical reasons (1,391 hospital days) and those due to non-medical reason (518 days). Using a previously published protocol, 74 parameters were evaluated. Delays in obtaining examinations or a specialist's consultation accounted for a small proportion of waiting days (1.9% of total hospital days), which was greater in patients who were not disabled (0.9% of hospital days) than in patients with total dependence (0.2% of hospital days). The delays resulted mainly from awaiting transfer either to another department or to a nursing home. The length of stay increased with severity of dependence. However, the number of days spent for transfer to a nursing home was also relatively high in the non-dependent patient group (42% of hospital days). This study demonstrates that neurologists cannot easily influence the length of stay in hospital. It also corroborates the need to develop short- and long-term chronic care facilities to facilitate the transfer of patients once there are no further medical reasons for staying in hospital.

We report two patients with subacute diffuse encephalopathy characterized by confusion, myoclonic encephalopathy, and mild akineto-rigid extrapyramidal signs in one case and by apathy, memory deficit, and partial complex seizures in the other. Hashimoto's thyroiditis with high titers of anti-thyroglobulin antibodies was diagnosed in both patients, who were unresponsive to anticonvulsant medication, but showed rapid neurological improvement following steroid treatment. On neuropsychological examination, predominant frontotemporal dysfunction was noted. Electroencephalographic activity was remarkable for its rhythmical delta activity, unresponsive to, or even paradoxically increased by, anticonvulsant treatment. On magnetic resonance imaging, atrophy with temporal predominance was found. These observations support the idea that this potentially treatable dementia and movement disorder should be classified as a separate clinical entity.

Neuronal growth factors hold promise for providing therapeutic benefits in various neurological disorders. As a means of ensuring adequate central nervous system delivery of growth factors and minimizing significant adverse side effects associated with systemic delivery methods, we have developed an ex vivo gene therapy approach for protein delivery using encapsulated genetically modified xenogeneic cells. Ciliary neurotrophic factor (CNTF) has been shown in various rodent models to reduce the motor neuron cell death similar to that seen in amyotrophic lateral sclerosis (ALS). The initial trials focusing on the systemic administration of CNTF for ALS have been discontinued as a result of major side effects, thus preventing determination of the potential efficacy of the molecule. In order to deliver CNTF directly to the nervous system, we conducted a phase I study in which six ALS patients were implanted with polymer capsules containing genetically engineered baby hamster kidney cells releasing approximately 0.5 microgram of human CNTF per day in vitro. The CNTF-releasing implants were surgically placed within the lumbar intrathecal space. Nanogram levels of CNTF were measured within the patients' cerebrospinal fluid (CSF) for at least 17 weeks post-transplantation, whereas it was undetectable before implantation. Intrathecal delivery of CNTF was not associated with the limiting side effects observed with systemic delivery. These results demonstrate that neurotrophic factors can be continuously delivered within the CSF of humans by an ex vivo gene therapy approach, opening new avenues for the treatment of neurological diseases.

We report the cases of two patients presenting a peculiar speech disorder, which we have named "echoing approval", in which the patients echo, in replying to questions in a dialogue with short phrases, the positive or negative syntactical construction of a question, or its positive or negative intonation, but without any repetition of whole or part of sentences. When asked about their symptoms, the patients replied 80% of the time with "yes, yes", "that's right", or "exactly" to positive questions and "no, no" or "absolutely not" to negative questions, regardless of their actual symptoms and oblivious to self-contradiction. In addition, when the examining doctor was speaking to a medical colleague in the patient's presence and using medical terminology that the patient did not understand, he/she agreed or disagreed with any sentence and technical word uttered in a way entirely dependent on the syntax or intonation used. To distinguish this speech disorder from echolalia or verbal perseverations, with which it may be superficially confused, we suggest that it be called "echoing approval", as it may be part one of the manifestations of the environment-dependency syndrome. This clinical picture was found to be associated with features of transcortical motor aphasia and frontal lobe signs. One patient had a bilateral callosofrontal malignant glioma and the other a probable multiple system atrophy with global deterioration, pre-eminent frontal release signs, diffuse leukoencephalopathy and multiple lacunes. On the basis of these clinical deficits and neuroimaging features, we are unable to delineate the common, or minimal, lesioned network required for this symptomatology to occur, especially in the absence of a series of patients, and with such a difference in both the location and causes of the lesions. However, bilateral frontosubcortical dysfunction was pre-eminent in the clinical picture in both patients, even though more diffuse brain pathology was seen in one, and it might be speculated that dysfunction of the bilateral orbitofrontal and frontomesial motor frontosubcortical circuits might be involved in the aetiology of this peculiar speech disorder.

Article abstract-We describe a patient who had sequential strokes in both hemispheres with a severe unilateral spatial neglect after a first right-sided parietal infarct and abrupt disappearance of the neglect after a second left-sided frontal infarct. The first lesion involved the caudalmost right angular gyrus (area 39), whereas the second lesion involved the left frontal eye field (area 8) and surrounding cortex. Those two cortical areas are assumed to have a pivotal role in modulating both shifts of attention within extrapersonal space and saccadic eye movements through their connections with subcortical structures, in particular, superior colliculi and thalamic nuclei. Our case supports the existence of a distributed anatomic-functional network in subserving directed spatial attention.NEUROLOGY 19;: 184-189

We studied 8 patients with stroke and hemineglect, who presented with a transient active orientation and explorative behavior, turning head, eyes, and trunk in the opposite direction to any stimuli given in the neglected hemispace, as if repelled. This peculiar active behavior increased on repetitive stimulation, with the patient turning over by more than 180 degrees, with extreme rotation and opisthotonos-like extension of the axial muscles, as if looking for something behind him, his pillow or his bed. This behavior fluctuated during the day and vanished after a few days. We coined the term "hyperneglect" for this behavior, postulating a higher degree in the neglecting behavior or an additional field of hemineglect in the non neglected hemispace, or the release of repellent active behavior from parietal origin by the acute lesion. On CT, five patients showed two sequential uni- or bilateral hemispheric strokes of different ages on CT, while two patients had a large, unilateral infarct associated with hypertensive leukoencephalopathy and contralateral brain edema respectively. This behavioral syndrome seems to be associated with an acute stroke involving the frontal or parietal lobes and a previous lesion in the same or the opposite hemisphere.

We report a patient with a small infarct in the posterior thalamic nuclei involving the pulvinar, probably in the territory of the lateral branches of the left posterior choroidal artery, who first pr

A patient with spontaneous intracranial dissection in the carotid system and fatal outcome is presented. A review of 59 patients reported in the literature shows that this condition has different epid

Atrial fibrillation (AF) is a risk factor for stroke, although it may not always be directly responsible for the stroke. On the other hand, cardiac arrhythmias and electrocardiographic changes have been reported after ischemic stroke and numerous other intracranial pathologies. We tested the hypothesis that some patients with acute stroke may develop transient AF as a consequence of the stroke. This study was based on 1,661 patients with first-ever stroke consecutively hospitalized and prospectively included into the Lausanne Stroke Registry. "Recent AF" was defined as AF discovered at or after ("after-admission" AF) admission in patients without any previous history of AF. Populations with recent AF and after-admission AF were compared for AF evolution, risk factors, and lesion type and distribution with patients with previous history of AF (known AF) and with patients with another recognized cardiac source of embolism (cardioembolic). Twenty-four patients had recent AF on admission, and 17 developed it a few hours to 3 days after stroke. AF disappeared after a few days in 26 (63%; 94% of after-admission AF) patients. Stroke was a primary hematoma in 9.8% of patients with recent AF, 2.8% of patients with known AF, and 0.9% (p < 0.001) of patients with cardiac source of embolism. Parietoinsular (32%) and brain stem (11%) involvement were more common in recent AF than in cardioembolic stroke in general (16.7% and 6.7%, respectively; p < 0.05). AF discovered after an acute stroke lasted no more than a few days, suggesting that it may have occurred as a consequence of the stroke. This possibility is emphasized by the significant predominance in patients with recent AF of primary hematoma, which cannot be caused by AF, and of parietoinsular and brain stem involvement, which are experimentally known as arrhythmogenic. This hypothesis should be considered in patients with acute stroke and previously unknown AF before therapeutic decisions are made.

We assessed the validity of clinical diagnosis of topography (CDT) and etiology (CDE) in 100 consecutive patients who were examined within 12 h of stroke onset by a stroke team (1 neurologist with int

167 of 1,802 patients with first strokes, admitted to a stroke primary care center and included prospectively into the Lausanne Stroke Registry had sensorimotor stroke (SMS) involving face/upper limb/

Intraluminal thrombi in the carotid circulation are uncommonly reported as a cause of stroke in young adults. We report two young women who suffered an embolic cerebral infarction from a floating thrombus in the innominate artery, without clotting abnormalities. Intraluminal thrombus at that level may have been previously overlooked as a cause of embolic cerebral infarction in young patients, because of the lack of a systematic assessment of the aortic arch and its proximal branches. Taking into account the fact that the evolution may be rapidly fatal, this possibility should be considered early in young patients without a clear etiology of stroke.

We studied 12 patients (6 men and 6 women) with a mean age of 47 years with stroke (n = 11) or transient ischemic attack (n = 1) in relation with an atrial septal aneurysm. Ten patients showed also a

Resume L'alpha-coma associe un coma et des modifications de l'EEG caracterisees par un rythme de base variant entre 8 et 13 Hz, d'une amplitude inferieure a 50 gmV, de repartition diffuse sur tout l'encephale, et depourvu de reactivite aux stimulations sensorielles. Vingt cas d'alpha-coma sont decrits: 16 cas sont en rapport avec une encephalopathie anoxique, deux cas concernent des accidents vasculaires dans le tronc cerebral, et deux cas sont secondaires a une encephalopathie metabolique. Les hypotheses concernant l'origine des modifications de l'EEG dans l'alpha-coma sont revues, bien que les mecanismes etiopathogeniques soient mal compris.

• We studied 13 patients with supranuclear lower cranial nerve ("pseudobulbar" or "suprabulbar") palsy of acute onset. While seven patients had had a prior stroke, six patients had no history of stroke. Eight patients experienced a complete bilateral supranuclear lower cranial nerve palsy, which was isolated in five patients and associated with hemiplegia and with hemiparesis in three patients. Pseudobulbar palsy was partial in five patients. Only one patient had neuropsychologic impairment. The pseudobulbar features improved or recovered within a few weeks in all patients. The common characteristic of the lesions on computed tomography or magnetic resonance imaging was the interruption of the corticonuclear pathways contrasting with marked sparing of the corticospinal pathways in both hemispheres. These lesions were either an opercular infarct, or a deep infarct in the corona radiata or internal capsule, or a lenticular hemorrhage. Hypertension was the most prevalent concomitant. Our findings suggest that acute pseudobulbar or suprabulbar palsy has rather stereotyped anatomic-vascular correlates and time course.

Two patients with bilateral thalamo-mesencephalic infarct in the paramedian territory developed vertical gaze dysfunction and marked behavioural changes, in the absence of significant motor inability and formal neuropsychological impairment. While they were physically and emotionally active before stroke, they became apathetic, aspontaneous, indifferent, and seemed to have lost motor and affectic drive, as well as the need itself for any psychic activity. However, this mental and motor inertia was reversible when the patients were repeatedly stimulated by another person. This need for constant external programming, together with a lack of emotional reactivity, made the patients resemble robots. CT and MRI suggested involvement of the dorsomedial and midline nuclei of the thalamus, and SPECT showed remote frontomesial hypoperfusion. A disturbance of the striatal-ventral pallidal-thalamic-frontomesial limbic loop is suggested by previous reports of a similar "loss of psychic self-activation", "pure psychic akinesia", or "athymhormia" with bipallidal, bistriatal, or subcortical bifrontal lesions.

In a 67-year-old man with left horizontal homonymous sectoranopia and slight facio-brachial hemiparesis, CT showed recent infarction in the right posterior choroidal-artery region. This particular vis

Small ''lacunar'' infarcts in the territory of the deep perforators (ITDP) have usually been attributed to small-vessel disease associated with hypertension or diabetes, but recently also to embolism

We evaluated the association between alcohol consumption and carotid atherosclerosis in 261 consecutive patients greater than 50 years old admitted to our community-based primary-care center with first ischemic stroke; their characteristics were entered into a computerized data bank (Lausanne Stroke Registry). Reported regular alcohol consumption was compared with the presence and severity of internal carotid artery disease as assessed by duplex scanning with spectral analysis of the Doppler signal and real-time B-mode imaging at the level of the carotid bifurcation. We found an inverse linear relation between light-to-moderate alcohol intake (less than or equal to 4 standard drinks/day) and severity of internal carotid artery stenosis. No conclusion could be drawn for heavier drinkers because there were too few. A logistic regression model showed that hypertension, cigarette smoking, and age in men and diabetes mellitus and cigarette smoking in women strongly counterbalanced the potential benefit of alcohol consumption. Although regular alcohol drinking cannot be advocated on the basis of our findings, light-to-moderate consumption of alcohol is the first factor to be inversely associated with extracranial carotid atherosclerosis in symptomatic patients with cerebrovascular disease.

A patient with idiopathic inflammation of the right orbit, established by biopsy, developed episodes of transient left sensorimotor hemiparesis. Neuroimaging showed intracranial extension of the disease with pronounced narrowing of the right internal carotid artery in its intracavernous portion. Oral cyclophosphamide induced gradual improvement. Transient ischaemic attack is rarely found in association with orbital disease and indicates possible intracranial extension.

Elaborate visual hallucinations limited to a hemifield are exceedingly rare. We report a patient with a right striatocapsular infarct who developed formed complex visual hallucinations restricted to t

Background and objective : To study consecutive patients with acute or delayed hyperkinetic movement disorders in the Lausanne Stroke Registry. Methods : We have identified 29 patients with acute or delayed movement disorders among 2500 patients who had their first-ever acute stroke in the Lausanne Stroke Registry. Setting : Department of Neurology, Lausanne University Hospital. Results : Our patients presented with hemichorea-hemiballism (11 patients), hemidystonia (5 patients), stereotypias (2 patients), jerky dystonic unsteady hand (3 patients), asterixis (2 patients), initial limb-shaking (2 patients), bilateral tremor (1 patients), bilateral jaw myoclonus (1 patient), hemiakathisia (1 patient) and dysarthria-dyskinetic hand (1 patieent). On neuroimaging a lesion was found in 25 of the 29 cases in the territory of the middle cerebral artery (7 deep, 2 superficial and 2 complete), the posterior cerebral artery (11 patients), both middle and posterior cerebral arteries (2 patients) or the anterior cerebral artery (1 patient). The jerky dystonic unsteady hand syndrome was associated with a specific lesion, an infarct in the territory of the posterior choroidal artery. Presumed small-vessel disease was the commonest cause of stroke (15 patients). Only 3 patients had persistent movements (> 6 months). Conclusion : Hyperkinetic movement disorders are uncommon in acute stroke (1 %), the commonest types being hemichorea-hemiballism and hemidystonia. These movement disorders are associated with stroke involving the basal ganglia and adjacent white matter in the territory of the middle or the posterior cerebral artery. The jerky dystonic unsteady hand syndrome is specifically associated with a small infarct in the territory of the posterior choroidal artery. The abnormal movements usually regress spontaneously. © 1997 Elsevier Science B.V. All rights reserved.

Article abstract-We studied 36 patients with MRI-proven isolated acute pontine infarct. Corresponding to the constant territories of intrinsic pontine vessels, infarcts followed a predictable distribution, enabling us to delineate three main syndromes. Twenty-one patients had a ventral pontine infarct. Motor involvement varied from mild hemiparesis (ventrolateral pontine syndrome) to severe hemiparesis with bilateral ataxia and dysarthria (ventromedial pontine syndrome). In addition, three-fourths of the patients had clinical evidence for usually mild tegmental dysfunction. Eleven patients had a tegmental pontine infarct, presenting tegmental signs (eye movement disorders, cranial nerve palsies, sensory disturbances), and mostly mild motor deficits (tegmental pontine syndrome). Only four patients had alternating deficits, and these never corresponded to any of the so-called classic pontine syndromes. Infarcts in the medial and the extreme lateral tegmental territory were never observed in isolation, being always associated with cerebellar or larger (and multiple) infarctions in the posterior circulation. Four patients with a bilateral ventrotegmental pontine infarct presented with acute pseudobulbar palsy, bilateral motor deficits, and tegmental signs.The results of etiologic work-up emphasize the concept of basilar artery branch disease, which was the most common presumed cause of stroke (16/36, 44%). Basilar artery branch disease was particularly associated with large ventral infarcts, severe clinical symptomatology, progressive or fluctuating course, and local recurrence. Presumed small-artery disease (9/36, 25%) was usually associated with small ventral or tegmental infarcts and rapidly improving lacunar syndromes. Large-artery stenosis (8/36, 22%) and cardioembolism (1/36, 3%) were less common than in series of posterior circulation infarcts that include simultaneous pontine and extrapontine lesions.Recovery was good in two-thirds of the patients, the worse outcome being associated with large ventral infarcts.NEUROLOGY 1996;46: 165-175

Summary Using a standard protocol including MRI and magnetic resonance angiography (MRA), we studied 28 consecutive patients, all with an acute infarct in the lower brainstem. MRI patterns above and below the inferior olivary nucleus enabled identification of six topographical types of infarct: small midlateral, dorsolateral, inferolateral, Iarge inferodorsolateral, dorsal and paramedian infarcts. Small midlateral, dorsolateral, inferolateral and inferodorsolateral infarcts were the most common types and were associated with Wallenberg's syndrome, with specific clusters and severity of neurological features in each of the four groups. Dorsal infarcts were both anatomically and clinically overshadowed by a constant associated cerebellar infarct in the posterior inferior cerebellar artery (PICA) territory. Paramedian infarction led to crossed tongue and sensorimotor hemiplegia, while a patient with an almost complete hemimedullary infarct had unusual ipsilateral sensory and motor disturbances due to lesion extension toward the upper spinal cord. A coexisting cerebellar infarct was present in 36% of the cases, but was never found with midlateral or inferolateral infarct. Angiography showed an embolic occlusion of the PICA in five patients (18%), four of them having dorsal or dorsolateral infarct. Atheromatosis was by far the most frequent stroke aetiology (72%), with intracranial vertebral artery tight stenosis or occlusion in 28% of the cases and in 75% of the cases with large inferodorsolateral infarct. Vertebral artery dissection and cardioembolism accounted each for 14% of the cases, the latter being associated with dorsal infarct. Our study shows that differences in topographical patterns of infarction in the lower brainstem probably reflect differences in aetiopathogenic mechanisms.

Within 12 hours of stroke onset 2506 patients with first ever stroke admitted to the Lausanne Stroke Registry were questioned about headache. Eighteen per cent of the patients reported headache, 14% with anterior circulation stroke and 29% with posterior circulation stroke (p < 0.001). Headache was reported by 16% of the patients with infarct and 36% of those with haemorrhage (p < 0.001). The prevalence of headache was 9% with lacunar infarct, 15% with middle cerebral artery territory infarct, 37% with infratentorial haemorrhage, and 36% with supratentorial haemorrhage. The most common topography of pain was frontal (41%), followed by diffuse headache (27%; p < 0.001). Diffuse (41%) or occipital (30%) headache was particularly frequent with posterior circulation stroke, whereas frontal headache was associated with anterior circulation stroke (51%; p < 0.001). Headache in stroke may be explained in part by involvement of blood vessels (acute distention or distortion) and mechanical (stretch of haemorrhage) stimulation of intracranial nociceptive afferents. Stroke due to dissection was strongly associated with headache (p < 0.001), whereas embolic (cardiac, artery to artery) stroke was more common without headache (p < 0.001), emphasising the role of extracranial v intracranial arteries in the genesis of headache at stroke onset. Moreover, dual trigeminal-vascular and cervical-vascular system involvement in causing headache may explain the lack of correspondence with the "rules of referral" in up to 38% of the cases.

Three patients developed a striking visual and motor behaviour in the acute phase of a stroke involving the territory of the right anterior parietal artery (postcentral gyrus, parts or upper and middle temporal gyri, anterior part of inferior parietal gyrus, and supramarginal gyrus). The patients concentrated on the left side of their bodies, looking at it for long periods and relentlessly rubbing, touching, pinching, pressing, lifting, and manipulating parts of the left arm, trunk, and leg with their right hand or foot. They all had severe loss of elementary sensation on the left (touch, pain, temperature, vibration, position). The behaviour was not associated with overinterest in the left hemispace apart from their own bodies. It lasted no more than a few days, disappearing when left sided sensation improved. The findings suggest an association between sensory dysfunction and this "acute hemiconcern". None of 13 patients with a mirror infarct in the left hemisphere and none of 38 patients with acute hemisensory loss due to thalamic capsular or brainstem stroke showed hemiconcern behaviour. This behaviour may result from a feeling of strangeness critically associated with hemisensory loss without hemispatial neglect, due to involvement of the right anterior parietotemporal region.

Motor behaviors on the 'good side' of the body, i.e. ipsilateral to the hemispheric lesion, have not been studied systematically. We assessed motor behaviors in 20 consecutive patients during the acute phase (first 1-2 weeks) of a hemispheric stroke with hemiparesis. The behaviors were essentially rotations of the head, neck, eyes and trunk, orofaciopharyngeal or limb stereotypes, compulsive manipulation of the surroundings, or passive mobilization of the paralyzed arm or leg. These behaviors were found only with large infarcts in the territory of the internal carotid artery, middle cerebral artery and/or the anterior cerebral artery (ACA). All but two ACA infarcts involved the internal capsule and basal ganglia. The severity of the motor deficit and the presence of aphasia, neglect, or sensory loss were significantly correlated with the motor behaviors. Although the understanding of these behaviors remains unclear, we suggest that they may represent the clinical expression of early plastic changes of brain maps and circuits after an acute lesion; this is probably an active process induced by disinhibition, in order to establish new compensatory pathways.

We studied 20 patients with an acute parietal stroke with hemisensory disturbances but no visual field deficit and no or only slight motor weakness, without thalamic involvement on CT or MRI and found three main sensory syndromes. (1) The pseudothalamic sensory syndrome consists of a faciobrachiocrural impairment of elementary sensation (touch, pain, temperature, vibration). All patients have an inferior-anterior parietal stroke involving the parietal operculum, posterior insula, and, in all but one patient, underlying white matter. (2) The cortical sensory syndrome consists of an isolated loss of discriminative sensation (stereognosis, graphesthesia, position sense) involving one or two parts of the body. These patients show a superior-posterior parietal stroke. (3) The atypical sensory syndrome consists of a sensory loss involving all modalities of sensation in a partial distribution. Parietal lesions of different topography are responsible for this clinical picture, which probably represents a minor variant of the two previous sensory syndromes. Neuropsychological dysfunction was present in 17 patients. The only constant association was between conduction aphasia and right-sided pseudothalamic sensory deficit. We conclude that parietal stroke can cause different sensory syndromes depending on the topography of the underlying lesion. Sensory deficits can be monosymptomatic but never present as a "pure sensory stroke" involving face, arm, leg, and trunk together.

A patient with anosmia and night blindness had repeated clinical and electrophysiological examinations during a 21-year period. Within the first 11 years, he experienced two subacute episodes of numbness with weakness and ataxia. Over the 10 ensuing years, no additional functional disability appeared. We looked retrospectively for a correlation between repeated manual muscle scoring and different nerve conduction parameters. Further studies were done in order to estimate reinnervation in proximal and distal muscles and to assess autonomic functions. A direct relationship was found between the magnitude of muscle weakness and the amplitude of compound muscle action potentials, whereas nerve conduction velocities were inhomogeneously reduced but almost unchanged over time. Parasympathetic tests were normal but sympathetic skin responses were absent. As estimated by macro-EMG and turns-amplitude analysis the compensatory reinnervation was very high. We conclude that, in Refsum's disease, recurrent segmental demyelination of a significant portion of the motor units can occur in parallel with exacerbations of weakness, and that a considerable degree of progressive motor and sudoromotor axonal loss can be found although there is an apparent long-term clinical stabilization of the neuropathy. © 1993 John Wiley & Sons, Inc.

In a prospective study of 70 patients with infarcts in the posterior circulation admitted consecutively to a population-based primary-care center, we assessed infarct location and etiology using magnetic resonance imaging, three-dimensional time-of-flight magnetic resonance angiography, and noninvasive cardiac tests. The brainstem (mainly the paramedian pons) was the most commonly infarcted site (41/70, 59%), followed by the cerebellum (33/70, 47%). Combined supra- and infratentorial multiple vertebrobasilar infarcts occurred in 11 patients (16%). Overall, 27 patients (39%) had > or = 50% stenosis or occlusion of the basilar artery. There were other large-artery lesions in 19 patients (27%), including vertebral (V2-V4) stenosis or occlusion (in seven) and dolichoectatic vertebral/basilar arteries (in 12). Fifteen of the 70 patients had a potential cardiac source of embolism, which coexisted with large-artery disease in more than one-third of the cases. Cerebellar infarct without concomitant brainstem or occipital infarct was associated with cardioembolism (67%), while isolated paramedian pontine or midbrain infarct was associated with basilar artery stenosis (71%), suggesting in situ occlusion of the mouth of the perforators off the stenosed basilar artery. After exclusion of other potential causes of stroke, presumed small-artery disease associated with chronic hypertension remained the likely etiology in only 11 patients (16%), but these infarcts were not associated with any of the classical lacunar syndromes. Our findings emphasize the high frequency of severe intracranial large-artery disease in posterior circulation infarcts.

The anti-Hu antibody is associated with a paraneoplastic subacute sensory neuronopathy (SSN) described in cases of small cell lung cancer (SCLC). The Hu antigen is a pan-neuronal nuclear antigen with a molecular weight of 35–40 kDa. In this study we demonstrated the presence of the paraneoplastic Hu antigen in different neuroblastoma cell lines. We showed that by indirect immunocytochemistry the serum of patients with SSN and SCLC reacts with the nuclei of neuroblastoma cell lines SKN-SH and LAN-1. Western blot analysis of nuclear extracts from neuroblastoma cell lines SKN-SH, IMR-32 and LAN-1 confirmed the presence of the Hu antigen in these neuroblastoma cell lines. By comparing the immunocytochemical method and the Western blot analysis we were able to determine that the Western blot analysis was a more sensitive test. Screening of the sera of a large population (a total of 122 patients with SCLC, 17 with paraneoplastic disorders as well as 121 controls with other neurological disorders) was performed and showed all 5 of the patients with SSN and SCLC to be positive for the anti-Hu antibody, whereas only 11 of the 122 SCLC patients and none of the controls were positive, thereby suggesting that this test has a very high degree of sensitivity.

Cranial dystonia is normally considered as a pure movement disorder. Sensory symptoms have not received much attention, but we found ill-defined pain, discomfort, distortion of sensory modalities, ‘phantom’ kinetic or postural sensations in the orofacial areas subsequently involved by the dyskinesia in all of 11 consecutive patients, preceding by weeks or months the motor syndrome. Physicians were often mislead, initially making diagnoses such as trigeminal neuralgia, dental problems, sicca syndrome, chronic conjunctivitis, glossitis or stomatitis. The patients reported that the orofacial movements were at first willingly performed in order to decrease the discomfort which was felt in these facial areas before the movements finally escaped voluntary control and became socially disturbing. We suspect that the sensory symptoms, for which no objective substrate could be found, and which were always reported before and in the exact location of the subsequent dyskinesia, could be the earliest manifestation of an evolving process in cranial and perhaps other focal dystonias.

We studied 34 consecutive patients with non-mass-producing cerebellar infarcts using a standard protocol of investigations including magnetic resonance imaging (MRI). We analyzed the topography of infarcts to determine the involved arterial territories and we correlated the findings with neurological dysfunction and potential causes of stroke. Sixteen patients had an infarct in the territory of the posterior inferior cerebellar artery (PICA); 2, in the territory of the anterior inferior cerebellar artery (AICA); 13, in the territory of the superior cerebellar artery (SCA); and 8 had junctional infarcts between the territories of the medial and lateral branches of the PICA or PICA/SCA territories. PICA or medial PICA territory infarcts were manifested by acute vertigo and truncal ataxia, while the patients with lateral PICA territory infarcts presented with unsteadiness, limb ataxia and dysmetria without dysarthria. Patients with infarcts in the AICA territory were characterized by limb and trunk ataxia associated with signs of lateropontine involvement. Patients with SCA territory infarcts presented with dysarthria, unsteadiness and/or vertigo, limb ataxia, and dysmetria. Cardiac embolism was the main cause of large infarcts in the territories of the PICA (8/16) or SCA (4/7). Multiple small infarcts were associated with vertebrobasilar atherosclerosis (8/12). These clinical-MRI correlations allow better definition of the topographic and etiological spectrum of cerebellar infarction, which was previously based on pathological studies in subjects with severe infarction.

• Objective. —To assess gadolinium—diethylenetriaminepentaacetic acid (Gd-DTPA) contrast—enhanced magnetic resonance (MR) imaging as an index of recent symptomatic small deep cerebral infarcts (SDCIs). Design. —Prospective case series. Settings. —Primary-care center. Patients. —Thirty-one consecutive patients presenting with the clinical diagnosis of SDCI in the territory of the perforators of the internal carotid artery or the vertebrobasilar system and confirmed by MR imaging. Intervention. —Rapid intravenous infusion of Gd-DTPA 5 to 10 minutes prior to acquisition of T 1 -weighted images. Main Outcome Measures. —Precise clinicotopographic correlation on MR scans. Results. —Non-contrast-enhanced MR imaging allowed precise clinicotopographic correlation in five (38%) of 13 patients with SDCI symptoms in the internal carotid artery territory. After Gd-DTPA administration, precise clinicotopographic correlation improved in 11 (85%) of 13 patients. In five patients, precise correlation was possible only after Gd-DTPA enhancement. Nonenhanced MR imaging allowed precise clinicotopographic correlation in 15 (83%) of 18 patients with SDCI symptoms in the vertebrobasilar territory. After Gd-DTPA administration, we could establish precise clinicotopographic correlation in all patients with SDCIs in the vertebrobasilar territory. In three patients, precise correlation was possible only after Gd-DTPA contrast enhancement. In seven (23%) of 31 patients, Gd-DTPA failed to enhance symptomatic lesion: in five patients MR scans were performed early (less than 7 days) and in two patients later in the course (greater than 7 days). Conclusions. —Although Gd-DTPA administration is unlikely to improve the sensitivity of MR images in visualizing SDCIs, it significantly improves the rate of precise clinicoanatomic correlation. All enhancing lesions showed precise clinicotopographic correlation. Enhancement may be absent in the acute phase (less than 7 days).

In patients with clinically isolated spinal disease, magnetic resonance imaging (MRI) provides a non-invasive method of detecting surgically treatable causes and is also useful in detecting asymptomatic brain lesions where the cord syndrome is due to multiple sclerosis (MS). We report the findings of spinal and brain MRI in 28 patients with spinal cord disorder due to MS. It was possible to detect intrinsic plaques reliably in the majority of patients (60.7%) with clinical findings of spinal cord MS. The results of MRI are compared with the clinical status and with cerebrospinal fluid findings and evoked potentials.

Listeria monocytogenes rhombencephalitis has never been studied in a significant group of patients. We describe 14 adult cases who were seen over a 10-year period. A biphasic illness was characteristic: (1) prodromes (5-15 days) with malaise, fatigue, headache, nausea or vomiting, and fever; (2) cranial nerve palsy with facial palsy, diplopia, dysphagia, dysarthria, usually multiple. Meningism and hemi- or tetraparesis were present in 11 patients and cerebellar dysfunction in 9 patients. In 4 cases, CT showed widening of the brain stem with disappearance of the surrounding cisterns. The cerebrospinal fluid was abnormal in all patients in whom this investigation was done (pleocytosis, elevation in protein content). The patients received antibiotic therapy for 2-6 weeks. In the 9 patients who recovered, the neurological dysfunction improved within 2 days to 1 week of the initiation of therapy. There were 5 deaths. At autopsy in 2 cases, there was severe purulent meningitis and rhombencephalitis with predominantly polymorphonuclear cellular infiltration in 1 case, while numerous microabscesses in the midbrain, pons and medulla were observed in the other. We conclude that L. monocytogenes infection should be considered in patients who develop fever and focal neurological signs particularly localized to the brain stem.

Until recent years, most studies on the topography of brain-stem and cerebellar infarcts were based on clinicopathological correlations. Magnetic resonance imaging (MRI) has greatly contributed to the diagnosis and accurate assessment of small infarcts located in the posterior fossa [1, 3, 6–8]. In this study, we examined the topographic distribution of isolated brainstem and cerebellar infarcts in relation to the involved arterial territories, as well as to the clinical presentation and pathogenesis of infarcts.

When blood flow through the internal and external carotid arteries is completely interrupted by ipsilateral common carotid artery occlusion, the arterial orbital circulation may be more compromised than the brain supply. We studied a pure and extreme example of this situation in a patient who presented with acute orbital infarction, but no cerebral ischemia on clinical, CT and single-photon emission computerized tomography (SPECT) grounds. Ipsilateral blindness corresponded to retinal, choroidal and optic nerve infarction. The pattern of ophthalmoplegia, with relative sparing of adduction, was more compatible with a muscle than a nerve dysfunction, but a reactive dilated pupil, corneal anesthesia, and orbital pain suggested that the intraorbital branches of the ocular motor nerves and ophthalmic division of the trigeminal nerve were not spared. In addition, signs of widespread ocular ischemia were present. Sequential examinations documented the evolution pattern over 1 year. The absence of an orbital collateral supply from the contralateral external carotid and muscular cervical arteries systems, which contrasted with an adequate middle cerebral artery supply via the contralateral internal carotid artery, may explain this isolated and complete form of orbital ischemia due to common carotid artery occlusion.

We report 5 patients with unilateral infarct and 1 with hemorrhage limited to the genu of the internal capsule. The most prominent finding was contralateral facial and lingual hemiparesis with dysarthria. Three patients also showed unilateral mastication-palatal-pharyngeal weakness, and 1 had unilateral vocal cord paresis. Mild limb involvement was limited to hand weakness in 4 patients. Our findings suggest that the majority of motor corticopontine and corticocobulbar fibers are located in the genu of the internal capsule. The faciolingual syndrome and its variants are highly suggestive of capsular genu stroke.

• We studied 27 patients with acute stroke and a corresponding infarct in the anterior cerebral artery territory, as disclosed using computed tomography. Patients were selected from 1490 patients (1.8%) admitted consecutively to a community-based primary care center who underwent standard investigations. An embolic phenomenon from the internal carotid artery or from the heart explained the infarct in 17 patients (63%). Anterior cerebral artery occlusion without a potential source of embolism was found only in one Vietnamese patient. Neurologic features correlated well with the topography and size of infarct, including hemiparesis, hemihypesthesia, mutism at onset, transcortical motor aphasia, conflictual tasks impairment, mood disturbances, and, more uncommonly, incontinence, grasp reflex, hemineglect, acute confusional state, and unilateral left apraxia. These findings suggest that the etiologic spectrum of anterior cerebral artery infarcts is the same as that of middle cerebral artery infarcts.

The aim of this trial was to compare the efficacy and tolerance of cyclosporine A (CYA) and azathioprine (AZA) as long-term immunosuppressive treatment for patients with multiple sclerosis. 31 randomly assigned patients completed a 12-month treatment with either CYA (5 mg/kg/day) or AZA (2 mg/kg/day). Evaluation included serial quantitative clinical assessments and circulating T cell markers. The CYA treatment group improved in only one of three scoring systems (p less than 0.05), while no difference was observed in the AZA group. CYA and AZA did not influence CD4+/CD8+ ratio of circulating T cells but affected HNK-1+ cells. The overall frequency of abnormal laboratory values were comparable in both groups. We conclude that CYA given in a low dose is relatively well tolerated but its benefits appear to be of limited value.

Recent observations have delineated the neurological manifestations of Lyme disease, but, to our knowledge, no detailed neuropathological study from autopsy cases has been reported. In this report we describe the neuropathological findings in a case of Lyme neuroborreliosis. The chronic meningitis, the occlusive meningo vascular and secondary parenchymal changes that we found are similar to those occurring in the meningovascular form of neurosyphilis. Thus, we suggest that the case described here represents the meningovascular form of tertiary Lyme neuroborreliosis.